Maryland Community College Students

Name (last, first, middle):

 

Any other name under which your educational record may be held:

Daytime phone number:  ( ) -

Evening phone number:  ( ) -

Fax number:  ( ) -  

E-mail address: (required)

Term for which you are applying

Fall
Spring
Summer

Have you already earned a college-level degree? Yes No

1. If yes, indicate below any degree you have already earned.
   
   Associate's degree
   Master's degree
   Professional degree (MD, JD)
   Bachelor's degree
   Doctoral degree Other __________________



2. Have you earned an associate's degree from or completed more than 45 credits from a Maryland community college?
   
   Yes   No

What is your academic goal in attending HCC and UMUC? (Check all that apply.)

I plan to earn an associate’s degree at HCC.
I plan to earn a certificate at UMUC.
I plan to earn a bachelor’s degree at UMUC.
I am undecided about my academic goal.

If you have previously attended UMUC, please indicate where and list dates of attendance.

In the United States
In Europe
In Asia

Dates:

If you attended UMUC courses on a military base, please indicate the base where you most recently attended class:

Gender:

Male
Female (optional)

Submission of this information is voluntary. This information will not be used to determine your admissibility to UMUC; it is being compiled for statistical purposes only.

Racial/ethnic category (optional) Submission of this information is voluntary. This information will not be used to determine your admissibility to UMUC; it is being compiled for statistical purposes only.

American Indian or Alaska native
Asian
Black or African American
Hispanic or Latino origin
Native Hawaiian or other Pacific Islander
White
Other or not reported: ____________________________________

Are you a U.S. citizen?

Yes   No

If no, please complete the following information and supply copies of all supporting documentation.

Country of birth:

Type of visa:

Alien registration no.:

Employer:

Employer’s zip+4:

Employment Start Date:

Social Security number ___________ - ___________ - ___________

Note: This will not be used as your student identification number. To view how UMUC may use your Social Security number, visit www.umuc.edu/ssn or call 800-888-8682.

Birthdate (Mo/Day/Yr):

Birthplace (city and state or country):  

Current mailing address:    Apt. no.:

City:        County:   State:

Zip+4:

County of residence (please enter code from list below):

How long have you lived at this address? 

Yrs:    Mos:

If you have lived less than one year at this address, please provide the following information.

Previous or permanent address:

City:    County: State: Zip+4:

How long did you live at this address? Yrs:    Mos:

Are you applying for any of the following types of aid?

Financial aid

Yes    No  

Veteran benefits

Yes    No

Golden ID benefits

Yes    No

Have you ever served in the military? Yes   No   

If yes, complete service information below and, if currently active duty, attach a copy of most recent assignment orders.

Active duty         Veteran        Veteran, disabled        Reserve component

Home state of record: Dates of service:

Duty station:

Branch of the military: Separation date (Mo/Day/Yr):

Are you the spouse or dependent of a full-time member of the U.S. Armed Forces?   

No
Yes (spouse)
Yes (dependent)

If yes, complete service information below and attach a copy of servicemember’s most recent assignment orders.

Home state of record: Dates of service:

Duty station:

Branch of the military:

Please indicate how you completed your secondary education.

High school        Name of high school:

Date of graduation (MO/Day/Yr):    City:   State:

GED      Date of exam (MO/Yr):

Do your GED scores total at least 225, with no score lower than 40 in any of the first 5 tests?

Yes   No   Study abroad     

Name of exam/certificate:   Date (MO/Yr):

List all colleges and universities previously attended, including Hagerstown Community College and any institutions of the University System of Maryland. We may deny transfer credit from any institution not listed below. To be eligible for transfer credit for previous college work, you must submit an official transcript from ALL colleges attended. To receive transfer credit for military experience, professional training, and credit by examination, you must submit appropriate documentation.

Please check the statement that most closely corresponds with your primary reason for attending HCC.

Exploration of new career or academic areas
Preparation for transfer to a four-year institution
Preparation for immediate entry into a career
To update skills for a job I currently hold
For interest and self-enrichment

Indicate your status at the last institution you attended:

In good standing
Academically dismissed within the last two years
Academic probation
Disciplinary dismissal in the past three years

Do you have at least a 2.0 grade-point average from the last college-level institution you attended?

Yes    No

Is English your native language?

Yes    No

Note: Applicants whose native language is not English must provide proof of English proficiency prior to admission. Please consult the UMUC catalog or Schedule of Classes for English proficiency criteria.

Have you ever been convicted in court for other than a misdemeanor or a minor traffic violation?

Yes    No

If yes, please explain separately and submit with your application.

Determination of Maryland Residency: Do you wish to be considered for in-state tuition status?  

Yes   No

If yes, you must complete the following questions. If no, skip to #37.

If any of the statements below apply to you, please check the appropriate box and provide the requested information. If none of the statements are applicable, skip to #27.

I am a part-time (50%) of full-time regular employee of the University System of Maryland (USM) or I am the spouse or financially dependent child of a regular USM employee.

Please indicate your USM status or relationship to the USM employee.

Please attach a letter of employment verification from the Office of Human Resources at the appropriate USM institution.

I am or my spouse is a full-time, active duty member of the US Armed Forces.

Please attach a copy of the most recent assignment orders and indicate date of expected separation from the military ________________________

I am the financially dependent child of a full-time, active duty member of the US Armed Forces who claims Maryland as his/her home of residency or resides in or is stationed in Maryland.

Please attach a copy of the servicemember’s more recent assignment orders and either the servicemember’s deed (or lease) or verification from the military that the servicemember has declared Maryland as his/her home of residency. Also, please indicate date of expected separation from the military. _________________

If you are seeking in-state status and did not select one of the statements in #28, you must complete the following questions. Failure to complete all of the required items may result in non-Maryland resident classification and out-of-state charges being applied. Residency classification information is evaluated in accordance with the University System of Maryland residency policy. If UMUC discovers that false or misleading information has been provided, you may be billed retroactively to recover the difference between in-state and out-of-state tuition. You may be contacted for additional information if necessary.

Please indicate your financial status:

I am financially independent. I have earned taxable income that covered one-half or more of my total expense for the past 12 months, and I have not been claimed as a dependent on another person’s most recent income tax returns. Go to #28.

I am financially dependent on another person who has provided me with one-half or more of my total expense for the past 12 months,and/or has claimed me as a dependent on his/her most recent income tax returns or I am a ward of Maryland. If you are a ward of Maryland, please attach documentation verifying your status and go to #37; otherwise, please supply the following information.

Provider’s name:    Relationship to applicant:

1. Length of time you have been financially dependent on provider (Yrs/Mos):



2. Is the provider a resident of Maryland?   Yes   No



3. Providers Address: Apt. no.:
   
   City:    County:   State:
   
   Zip+4:



4. Is the provider a US citizen? Yes   No     If no, type of visa: ________________________________________
   
   Expiration date (MO/Day/Yr):     Alien registration no:________________________________________
   
   Date issued (MO/Day/Yr):



5. Has the provider filed a Maryland income tax return for the most recent year on all earned income, including taxable income earned outside the state?   Yes   No    
   
   If yes, list the year(s) in which a Maryland income tax return has been filed within the past 3 years:    
   
   If a Maryland tax return has not been filed within the past 12 months, state the reason(s):



6. Signature of provider:____________________________________________________________

Permanent address: Apt. no.:

City:    County:   State:   Zip+4:

How long did you live at this address? Yrs: Mos:

If you have lived less than one year at your current address, please provide the following information.

Previous address: Apt. no.:

City:    County:   State:   Zip+4:

How long did you live at this address? Yrs: Mos:

Do you have a valid driver’s license?   Yes   No 

1. If yes, provide the original date of issue for your current license (MO/Yr): From which state was the license issued?



2. Were you previously licensed to drive in another state?    Yes   No

Do you own a motor vehicle?   Yes   No  

1. If yes, provide the original registration date: In which state is it registered?



2. Was your motor vehicle previously registered in another state?    Yes   No

Are you registered to vote?  Yes   No

1. If yes, in which state?      Provide the original voter registration date (MO/Yr):



2. Were you previously registered to vote in another state?    Yes   No

Have you filed a Maryland income tax return for the most recent year?    Yes   No

Have you paid local income taxes for the most recent year?    Yes   No

1. List the year(s) in which you filed a Maryland income tax return within the past three years:
   
   
   
   
2. If you did not file a tax return in Maryland within the past 12 months, state the reason(s):
   
   

Are you currently paying Maryland income tax, either through payroll deduction or quarterly estimated payments?   No    Yes  

If no, why not?

Do you receive public assistance from a state or local agency other than one in Maryland?

No    Yes  

If yes, please explain:

________________________________________________________________________

Signature of applicant                         Date of application (Mo/Day/Yr)

________________________________________________________________________

Signature of provider                          Date of application (Mo/Day/Yr)